Autumn Care Of Myrtle Grove

F-F693: Based on record review, Nurse Practitioner (NP), Medical Director, staff, and Responsible Party (RP) interviews, the facility failed to ensure a resident (Resident #1) was provided with the necessary treatment to replace his dislodged jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine). On 1/25/25, Nurse #1 did not identify the need for hospital treatment to replace the dislodged jejunostomy tube (j-tube) and she inserted an indwelling urinary catheter tube to replace the j-tube without a physician's order. The replacement tube became dislodged from the j-tube site on 1/25/25, and Nurse #1 sent the resident to the hospital for reinsertion. Resident #1 went to the Operating Room (OR) on the evening of 1/27/25 and the j-tube was successfully placed. This noncompliance created a high likelihood of Resident #1 suffering serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis (life-threatening infection), and bleeding due to anticoagulant (blood thinner) use. This deficient practice was identified for 1 of 3 residents reviewed for feeding tubes.

Review of Nurse #1's employee record verified she was hired by the facility on 1/10/25 as an agency licensed practical nurse (LPN). There was no evidence of competency and training regarding j-tubes in her file.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Review of the facility training for agency nurses did not identify specific training and competency for j-tubes.

Level of Harm - Immediate An interview was completed with Nurse #1 on 1/23/25 at 10:00 AM. Nurse #1 stated she was an experienced jeopardy to resident health or nurse, and she had completed training regarding gastrostomy tubes and jejunostomy tubes at other facilities safety she had worked at. She further stated she did not recall completing training specifically regarding j-tubes when she was in orientation at this facility. Residents Affected - Few

An interview was completed with the Director of Nursing (DON) on 4/23/25 at 4:10 PM. The DON stated the agency was responsible for verifying a nurse's training and competencies prior to employment by the facility.

She indicated the facility's orientation for agency nurses did not include specific competency and training for j-tubes at the time of Nurse #1's employment.

The Administrator was notified of immediate jeopardy on 4/23/25 at 4:00 PM.

The Administrator provided the following credible allegation of Immediate Jeopardy removal:

Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of

the noncompliance:

The facility failed to ensure Nurse #1 was trained and competent to provide the necessary care and treatment for residents with jejunostomy tubes (j-tubes). Nurse #1 did not identify the need for hospital treatment to replace Resident #1's dislodged j-tube and she inserted an indwelling urinary catheter tube to replace the tube. Surgical Residents were able to place an indwelling urinary catheter tube into the tract in

the emergency room (ER). Interventional Radiology (IR) attempted placement on January 27, 2025 but were not able to place. Resident #1 went to the Operating Room (OR) on the evening of January 27, 2025 and the j-tube was successfully placed. Resident #1 returned to the facility on [DATE REDACTED]. During the remainder of Resident #1's time at facility, the j-tube did not dislodge again. Resident #1 was discharged from the facility

on March 28, 2025.

On April 23, 2025, the Director of Nursing (DON) reviewed all residents that resided in the facility from [DATE REDACTED] until April 23, 2025 and no additional residents were identified with a j-tube in the facility at this time.

Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete:

The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers will provide education to Licensed Nurses on Gastrostomy Tube Reinsertion Policy, to include what to do if a j-tube becomes dislodged to include physician notification, not to attempt reinsertion of the j-tube and risks and sending the resident to the hospital for surgical reinsertion. A quiz was created to validate staff understanding of the material that was taught. Any nurse that cannot answer the quiz questions appropriately will be retrained by the DON or ADON on the material. Training will be completed by April 24, 2025. The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 New hires and Agency Nurses will be educated by the DON or ADON during the orientation process using

the Gastrostomy Tube Reinsertion Policy. The quiz will be given at the end of their training to validate Level of Harm - Immediate understanding on what to do if a j-tube becomes dislodged to include physician notification, not to attempt jeopardy to resident health or reinsertion of the j-tube and risks and sending the resident to the hospital for surgical reinsertion. safety Alleged immediate jeopardy removal date: April 25, 2025. Residents Affected - Few

The immediate jeopardy removal plan was validated on 4/24/25. The audit of 100% of residents with feeding tubes verified there were no other residents with j-tubes identified. The educations sign in sheets were reviewed for in-services conducted with the nurses on 4/23/25 and 4/24/25 regarding the facility's Gastrostomy Tube Reinsertion Policy which included education regarding what to do if a j-tube becomes dislodged including physician notification, not attempting reinsertion of the j-tube, risks involved in reinsertion, and sending the resident to the hospital for surgical reinsertion. Staff interviews confirmed education and a quiz on gastrostomy tubes, j-tubes, and what to do if a jejunostomy becomes dislodged. The validation quizzes were reviewed with no concerns. The DON stated on 4/24/25 at 12:22 PM that all the nurses, including new hires and agency nurses, would have to pass the validation quiz for competency regarding feeding tubes. The facility's immediate jeopardy removal date of 4/25/25 was validated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40044 potential for actual harm Based on record review, staff and the Medical Director's interviews the facility failed to hold a fast-acting Residents Affected - Few insulin (insulin that begins working within 15 minutes after administration) as ordered by the physician for a blood sugar level less than 150. Resident #4 was administered 2 units of sliding scale insulin with a blood sugar of 103. This occurred for 1 of 1 resident (Resident #4) reviewed for unnecessary medications.

Findings included.

Resident #4 was admitted to the facility on [DATE REDACTED] with diagnoses including diabetes.

A physician's order for Resident #4 dated 1/6/25 and discontinued on 1/31/25 revealed Humulin R Regular insulin U-100 insulin 100units per milliliter. Administer per sliding scale as follows: No sliding scale coverage for blood sugar less than 150.

The Minimum Data Set (MDS) admission assessment dated [DATE REDACTED] revealed Resident #4 was nonverbal and unable to assess cognition. He received insulin.

Review of the Medication Administration Record (MAR) dated January 2025 for Resident #4 revealed Humulin R sliding scale insulin was signed off by Nurse #1 as 0 (zero) units administered at 11:00 AM on 1/25/25. The blood sugar reading was 103.

During a phone interview on 4/23/25 at 9:10 AM Nurse #1 stated she administered insulin to Resident #4 in error on 1/25/25. She stated on 1/25/25 she checked Resident #4's blood sugar and recalled his blood sugar was in the low 90's or 100's, and she told his family who were in his room at the time that he would not need

the sliding scale insulin. She stated she went back to the medication cart and three nurse aides approached her with problems which distracted her. She then drew up 2 units of insulin and administered it to Resident #4. Once she administered the insulin the family stated they thought he didn't need insulin, and she realized then that he wasn't supposed to get the 2 units that she had just administered. She stated she checked Resident #4's blood sugar following the medication error and his blood sugar remained stable. She stated

she reported the medication error to the Director of Nursing (DON) that day. Nurse #1 stated if she documented 0 units administered then it was signed in error because she did give 2 units of insulin at 11:00 AM on 1/25/25. She stated she worked until 7:00 PM on that date and Resident #4 never had any signs or symptoms of low blood sugar. She stated the insulin was administered in error.

During a phone interview on 4/23/25 at 11:55 AM the Medical Director stated administering 2 units of sliding scale insulin would not cause Resident #4 any harm and there were no reports made to her of concerns with his insulin or his blood sugar. She indicated if Resident #4 had experienced any negative outcome from receiving insulin when it was not needed she would have wanted to be notified but there had been no reported concerns. She stated the physician orders for administering sliding scale insulin should have been followed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 During an interview on 4/23/25 at 2:00 PM the Director of Nursing (DON) stated she was made aware of the medication error by Nurse #1 on 1/25/25. She stated Nurse #1 was no longer employed with the facility and Level of Harm - Minimal harm or she had been unable to contact Nurse #1 since that time. She stated Nurse #1 should not have administered potential for actual harm Resident #4 sliding scale insulin with a blood sugar reading less than 150. She stated Resident #4 did not experience any negative outcome from receiving the insulin in error. She indicated since that time she had Residents Affected - Few provided education to staff regarding medication administration and further education would be provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40044 potential for actual harm Based on record review, staff, the Nurse Practitioner and Physician interviews, the facility failed to obtain an Residents Affected - Few ordered urinalysis and culture and sensitivity (a urine test obtained to identify the presence of bacteria. A urine culture identifies the presence and type of bacteria causing an infection. Sensitivity tests determine which antibiotics are effective against the bacteria) for a resident experiencing symptoms of burning, urgency and decreased urinary output for 1 of 1 resident (Resident #3) reviewed for laboratory services.

Findings included.

Resident #3 was admitted to the facility on [DATE REDACTED] with diagnosis including chronic kidney disease.

A physician progress note dated 4/15/25 revealed Resident #3 was assessed due to suspected urinary tract infection due to dysuria (painful urination), urinary frequency and urgency. The plan of care was to test a urine culture to evaluate for urinary tract infection.

A physician's order dated 4/15/25 at 11:07 AM was entered by Nurse #4 for Resident #3 to obtain a urinalysis and culture and sensitivity for evaluation of urinary tract infection due to complaints of dysuria, frequent urination, and urgency.

A physician's order dated 4/15/25 at 11:12 AM for Resident #3 revealed Cephalexin (antibiotic) 500 milligrams (mg) three times a day due to possible urinary tract infection and dysuria.

A nursing progress note dated 4/15/25 at 6:32 PM written by Nurse #4 indicated a urinalysis and culture and sensitivity test was pending to rule out a urinary tract infection. Resident #3 complained of burning, urgency and a small amount of urine output. An antibiotic was started according to the physician's order.

The Minimum Data Set (MDS) admission assessment dated [DATE REDACTED] indicated Resident #3 had moderately impaired cognition and was frequently incontinent of bowel and bladder.

A Nurse Practitioner note dated 4/22/25 indicated Resident # 3 remained on antibiotics for suspected urinary tract infection with complaints of intermittent discomfort with urination. The Nurse Practitioner indicated that Resident #3 had a suspected urinary tract infection due to dysuria, urinary frequency, and urgency.

Review of Resident #3's electronic medical record from 4/15/25 through 4/24/25 revealed no results from the urinalysis and culture and sensitivity report.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0770 During an interview on 4/24/25 at 12:15 PM the Nurse Practitioner stated a urinalysis with culture and sensitivity was ordered for Resident #3 on 4/15/25 by Physician #2. She stated they did not get the lab Level of Harm - Minimal harm or results back and then discovered on 4/23/25 that the urine sample was still in the refrigerator in the facility potential for actual harm and was never picked up by lab services. She stated the nurse who obtained the urine sample (Nurse #4) told her she did obtain the urine sample from Resident #3 via urinary catheterization on 4/15/24. She stated Residents Affected - Few the urinalysis should have been obtained and sent to the lab when the order was written. She stated Resident #3 continued with mild symptoms, but he did not want to be catheterized again at this time. The plan now was to reevaluate Resident #3 on Monday 4/28/25 and a urinalysis would be obtained at that time if needed.

During an interview on 4/24/25 at 12:30 PM Nurse #4 stated she received the order for the urinalysis on 4/15/25 and collected the urine sample from Resident #3 that day. She stated she entered the information into the electronic medical record and into the lab services website. She indicated that she did not recall if

she recorded it in the lab book for pick up.

During an interview on 4/24/25 at 1:00 PM the Unit Manger stated Resident #3's urine sample was obtained

on 4/15/25 by Nurse #4 and the order was entered into the electronic medical record and into the lab services database to collect the urine. She stated the process included that once the order was entered into

the residents medical record by the nurse, the nurse then had to enter the order into the lab services website and print a requisition form (informs the lab of what tests to perform) and then record it in the lab book which was kept at the nurses station. When the lab company comes to the facility they review the lab book to determine what needed to be collected. She stated the breakdown was that the order was not entered into

the lab book therefore the lab did not pick up the urine sample. She indicated she usually checked the lab book to ensure the labs were recorded. She stated it was done in error.

During an interview on 4/24/25 at 2:00 PM the Director of Nursing stated she was not aware of the urine sample obtained for urinalysis not being picked up from the lab for Resident #3. She stated a process was in place for obtaining labs and the process was not followed. She stated once the lab order was entered into

the resident's medical record it also had to be written in the lab book and that was not done. She stated education would be provided.

During an interview on 4/24/25 at 3:00 PM Physician #2 stated she was made aware of the urinalysis not being collected today. She indicated there had been no significant outcome from not obtaining the urinalysis with culture and sensitivity. She stated Resident #3 remained on antibiotics for urinary tract infection and she expected lab orders to be entered correctly, and results made available and that was not done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44890

Residents Affected - Few Based on record review and staff interview, the facility failed to maintain complete and accurate medical records for 2 of 11 residents whose medical records were reviewed (Resident #1 and Resident #4).

Findings included.

1.) Resident #1 was admitted to the facility on [DATE REDACTED].

The physician's orders for Resident #1 revealed orders dated 1/14/25 for:

- a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size)

- tube feeding at a continuous rate of 70 milliliters (ml) an hour for 22 hours to allow for activities of daily living

- amlodipine (used to treat high blood pressure) 5 milligrams (mg) tablet per feeding tube, once a day for hypertension (high blood pressure)

- cetirizine 10 mg tablet once a day per feeding tube for seasonal allergies

- apixaban 5 mg tablet twice a day per feeding tube for anticoagulant (blood thinner)

- loratadine 10 mg tablet once a day for allergies

The January 2025 Medication Administration Record (MAR) for Resident #1 listed Eliquis, Loratadine, Amlodipine, and Cetirizine as administered via j-tube by Nurse #1 on 1/25/25 during the 7:00 AM to 11:00 AM medication pass.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 A partially filled out SBAR (Situation, Background, Appearance, Review and Notify is a structured communication tool used to transmit clear concise information) 4 page form in the chart dated 1/25/25 and Level of Harm - Minimal harm or signed by Nurse #1 listed the Situation was: The change in condition, symptoms, or signs observed and potential for actual harm evaluated were Resident #1 pulling out his jejunostomy tube (j-tube) twice and the condition was listed as occurring before due to resident consistently playing and tugging on the tube. In the section under Residents Affected - Few Background: the box was checked that the resident was in the facility for long-term care. The areas that were not completed were the primary diagnosis, other pertinent history, Medication Alerts for changes, anticoagulants, hypoglycemics, allergies, and vital signs including pulse oximetry (measures the oxygen saturation in the blood cells). The Resident Evaluation was not completed regarding his mental and functional status, behavioral evaluation, respiratory evaluation, cardiovascular evaluation, abdominal/gastrointestinal (GI) evaluation, Genitourinary/Urine evaluation, skin evaluation, pain evaluation, neurological evaluation, and care plan information. There was a box at the top of the evaluations to check if

the area was not clinically applicable to the change in the condition being reported. The Section regarding Appearance was not filled out. In the section to Review and Notify the box to call for 911 for transfer to the hospital was checked. Resident #1's name was listed on the form, the Responsible Party (RP) was notified at 12:51 PM, the on-call provider was notified at 1:12 PM and the form was signed and dated by Nurse #1 on 1/25/25 at 12:51 PM.

An interview with Nurse #1 was completed on 4/23/25 at 10:00 AM. Nurse #1 stated she was the nurse assigned to care for Resident #1 on 1/25/25 when his j-tube became dislodged. She further stated the residents she was assigned to care for that day were high acuity (residents requiring closer monitoring and treatments with i.e. tracheostomy tubes, feeding tubes, wounds) and she had not completed the documentation related to the incident. Nurse #1 indicated that the Director of Nursing (DON) called her multiple times to return to the facility to complete the paperwork, but she never went back to the facility. Nurse #1 also stated she did not administer Eliquis, Loratadine, Amlodipine, and Cetirizine to Resident #1 on 1/25/25 during the 7:00 AM to 11:00 AM medication pass. She stated that she must have checked the medications off on the MAR as administered when she pulled them from the medication cart, but she did not administer the medications.

An interview with the DON was completed on 4/23/25 at 4:00 PM. The DON stated she tried to call Nurse #1 multiple times to get her to come back to the facility to complete the paperwork regarding Resident #1's transfer to the hospital, but she never came back. She indicated she expected the nursing staff documentation to be complete and accurate.

40044

2.) Resident #4 was admitted to the facility on [DATE REDACTED] with diagnoses including diabetes.

A physician's order for Resident #4 dated 1/6/25 and discontinued on 1/31/25 revealed Humulin R Regular insulin U-100 insulin 100units per milliliter. Administer per sliding scale as follows: No sliding scale coverage for blood sugar less than 150.

Review of the Medication Administration Record (MAR) dated January 2025 for Resident #4 revealed Humulin R sliding scale insulin was signed off by Nurse #1 as 0 (zero) units administered at 11:00 AM on 1/25/25. The blood sugar reading was 103.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 During a phone interview on 4/23/25 at 9:10 AM Nurse #1 stated she administered insulin to Resident #4 in error on 1/25/25. She stated on 1/25/25 she checked Resident #4's blood sugar and recalled his blood sugar Level of Harm - Minimal harm or was in the low 90's or 100's. She stated she went back to the medication cart and three nurse aides potential for actual harm approached her with problems which distracted her. She then drew up 2 units of insulin and administered it to Resident #4. Once she administered the insulin the family stated they thought he didn't need insulin, and Residents Affected - Few she realized then that he wasn't supposed to get the 2 units that she had just administered. Nurse #1 stated if she documented 0 (zero) units administered then it was signed in error because she did give 2 units of insulin at 11:00 AM on 1/25/25. She stated she should have documented that 2 units of insulin was administered to Resident #4.

During an interview on 4/23/25 at 2:00 PM the Director of Nursing (DON) stated she was made aware of the medication error by Nurse #1 on 1/25/25. She stated Nurse #1 should not have administered Resident #4 sliding scale insulin with a blood sugar reading less than 150 and she was not aware that she documented in error on the MAR. She stated Nurse #1 should have documented on the MAR that she administered 2 units of insulin to Resident #4. She indicated education would be provided regarding accurately documenting in

the medical record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 44890 potential for actual harm Based on observations, record review, and staff interviews the facility failed to implement the infection control Residents Affected - Some policy and procedures for Enhanced Barrier Precautions (EBP) when providing direct care activities to residents. Nurse #2 and Nurse #3 provided tracheostomy (an opening surgically created in the neck to insert

a tube into the trachea (windpipe) allowing for air to enter the lungs directly) care which included tracheal suctioning (a procedure to remove excess secretions from the airway). Nurse #2 also administered a tube feeding through a gastrostomy tube (a feeding tube placed directly into the stomach). The nurses donned gloves and a mask but no gown during the procedures. This occurred for 2 of 2 staff members (Nurse #2, and Nurse #3) who were observed for infection control practices.

Findings included:

The facility's Infection Control Policy revised 03/15/25 revealed Enhanced Barrier Precautions (EBP) were intended to prevent transmission of multi-drug-resistant organisms (MDRO's) via contaminated hands and clothing to high-risk residents. Enhanced Barrier Precautions were indicated for high contact care activities for residents with chronic wounds or indwelling devices such as tracheostomies and gastrostomy tubes.

1.) A blue Enhanced Barrier Precautions (EBP) sign was noted outside Resident #2's door. The sign read in part, Perform hand hygiene with alcohol based handrub (ABHR) or wash with soap and water before entering and leaving room .Wear gown and gloves for the following High Contact Resident Care Activities which include: Dressing, bathing/showering, Transferring, changing linens, changing briefs or assisting with toileting, and Device care or use; central lines, urinary catheter, feeding tubes, tracheostomy, Wound care: any skin opening requiring a dressing.

An observation of Nurse #2 performing tracheostomy (a surgically created hole through the neck into the trachea (windpipe) to allow air to fill the lungs) suctioning and providing bolus feeding through a gastrostomy tube (a feeding tube place directly into the stomach) for Resident #2 was conducted on 4/22/25 at 2:07 PM. Nurse #2 performed hand hygiene with ABHR prior to applying gloves and was observed suctioning Resident #2's tracheostomy without wearing a protective gown. Nurse #2 removed her soiled gloves and used ABHR sanitizer prior to donning clean gloves. Nurse #2 was observed providing bolus tube feeding through Resident #2's gastrostomy tube without a protective gown.

An interview with Nurse #2 was completed on 4/22/25 at 2:25 PM. Nurse #2 stated she was unaware she was supposed to be wearing a protective gown while performing procedures involving tracheostomy and tube feeding care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 345507 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 345507 B. Wing 04/24/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 An interview was completed with the Assistant Director of Nursing (ADON) /Infection Control Preventionist (ICP) on 4/22/25 at 2:31 PM. The ADON/ICP stated she had only worked at the facility for a about 6 months. Level of Harm - Minimal harm or She stated she was the Staff Development Coordinator (SDC) prior to receiving her SPICE training just a potential for actual harm couple of weeks ago. The ADON/ICP further stated that the nursing staff were educated multiple times in the last 6 months involving Enhanced Barrier Precautions. She indicated the nursing staff were to follow the Residents Affected - Some enhanced barrier precaution signs posted outside of the residents' rooms. The ADON/ICP stated Nurse #2 should have been wearing a protective gown while performing tracheostomy suctioning and providing bolus tube feeding for Resident #2.

An interview with the Director of Nursing (DON) occurred on 4/24/25 at 9:20 AM. The DON stated Nurse #2 was supposed to follow the Enhanced Barrier Precautions while performing tracheostomy suctioning and bolus tube feeding. She further stated Nurse #2 should have been wearing a gown while performing hands

on care for a resident with a tracheostomy and a feeding tube. The DON indicated she expected the nursing staff to follow the facility's infection control policies and procedures while performing care for the residents.

She stated the facility needed to continue conducting audits and providing education to the nursing staff.

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2.) During an observation on 4/22/25 at 5:00 PM Nurse #3 was observed providing tracheostomy care including performing tracheal suctioning to Resident # 5. Nurse #3 was wearing gloves, and a mask but no gown while providing direct care. A sign was located outside of the residents room indicating Resident #5 was on Enhanced Barrier Precautions and to don gloves, gown, and a mask prior to performing direct care activities. A supply cart with gowns and gloves was located outside of Resident #5's room.

During an interview on 4/22/25 at 5:00 PM Nurse #3 stated she should have put on a gown along with the gloves and mask before providing Resident 5#'s tracheostomy care. She stated she had received education

on Enhanced Barrier Precautions and using personal protective equipment. She stated it was done in error.

During an interview with the Infection Control Preventionist Nurse on 4/23/25 at 11:00 AM she stated Resident #5 was on Enhanced Barrier Precautions due to having a tracheostomy. She indicated a sign was located outside of Resident #5's room along with a supply cart. She stated the nurses had received education on Enhanced Barrier Precautions and donning personal protective equipment (PPE) and were aware of the policy. She stated further education would be provided.

During an interview on 4/24/25 at 2:00 PM the Director of Nursing (DON) stated staff had been trained on Enhanced Barrier Precautions and were aware that personal protective equipment including gloves, gown, and masks were required when providing direct care such a tracheostomy care. She stated Nurse #3 should have donned a gown along with gloves and a mask prior to providing care. She stated education would be provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 345507